A slew of studies from around the world has reported a disturbing trend: since the coronavirus pandemic started, there has been a significant rise in the proportion of pregnancies ending in stillbirths, in which babies die in the womb. Researchers say that in some countries, pregnant women have received less care than they need because of lockdown restrictions and disruptions to health care. As a result, complications that can lead to stillbirths were probably missed, they say.
“What we’ve done is cause an unintended spike in stillbirth while trying to protect [pregnant women] from COVID-19,” says Jane Warland, a specialist in midwifery at the University of South Australia in Adelaide.
The largest study to report a rise in the stillbirth rate, based on data from more than 20,000 women who gave birth in 9 hospitals across Nepal, was published in The Lancet Global Health on 10 August1. It reported that stillbirths increased from 14 per 1,000 births before the country went into lockdown to stop the spread of the coronavirus in late March, to 21 per 1,000 births by the end of May — a rise of 50%. The sharpest rise was observed during the first four weeks of the lockdown, under which people were allowed to leave their homes only to buy food and receive essential care.
The study, led by Ashish K.C., a perinatal epidemiologist at Uppsala University, Sweden, and his colleagues, found that although the rate of stillbirths jumped, the overall number was unchanged during the pandemic. This can be explained by the fact that hospital births halved, from an average of 1,261 births each week before lockdown to 651. And a higher proportion of hospital births during lockdown had complications. The researchers don’t know what happened to women who didn’t go to hospital, or to their babies, so they cannot say whether the rate of stillbirths increased across the population.
The increase in the proportion of stillbirths among hospital births was not caused by COVID-19 infections, says K.C.. Rather, it is probably a result of how the pandemic has affected access to routine antenatal care, which might have otherwise picked up complications that can lead to stillbirth, he says. Pregnant women might have been unable to travel to health facilities for lack of public transport; in some cases, antenatal appointments were reportedly cancelled. Others might have avoided hospitals for fear of contracting SARS-CoV-2, the virus that causes COVID-19, or had consultations by phone or Internet. Disruptions brought about by the pandemic have also been linked to a rise in deaths from heart disease and diabetes.
“Nepal has made significant progress in the last 20 years in health outcomes for women and their babies, but the last few months have deaccelerated that progress,” says K.C..
Birth data from a large hospital in London showed a similar trend. In July, Asma Khalil, an obstetrician at St George’s, University of London, and her colleagues reported2 a nearly fourfold increase in the incidence of stillbirths at St George’s Hospital, from 2.38 per 1,000 births between October 2019 and the end of January this year, to 9.31 per 1,000 births between February and mid-June.
Khalil calls this the collateral damage of the pandemic. She says that during lockdown, pregnant women might have developed complications that were not diagnosed, and might have hesitated about coming to hospital and therefore been seen by doctors only when a complication was advanced, when less could be done.
Four hospitals in India also reported3 a jump in the stillbirth rate during the country’s lockdown. And as in Nepal, fewer women had their babies in those hospitals. Referrals of women requiring emergency pregnancy care also dropped by two-thirds. This suggests that more births were happening unattended, at home or in small facilities, according to the authors. Scotland — one of a few countries that collates data on stillbirths and infant deaths monthly — has also detected an uptick in the rate of stillbirths in the months of the pandemic.
In normal times, the World Health Organization recommends that women be seen by medical professionals at least eight times during pregnancy — even if the pregnancy is judged low-risk — to detect and manage problems that might harm the mother, the baby or both. Much of the risk of stillbirth can be averted if women sleep on their side from 28 weeks’ gestation, stop smoking and notify their midwife or doctor if their baby is moving less. The last trimester of pregnancy is particularly important for regular health checks, but women are typically monitored for risk factors such as restricted fetal growth and high blood pressure throughout pregnancy.
When the pandemic hit, professional bodies for maternity health providers recommended that some face-to-face consultations be substituted with remote appointments to protect women from the coronavirus.
But health-care workers can’t take someone’s blood pressure, listen to their baby’s heartbeat or do an ultrasound remotely, says Warland. Because of this, high-risk pregnancies might have been missed, she says, particularly among first-time mothers who are less likely to know what an abnormality feels like. For instance, St George’s Hospital reported a drop in the number of pregnant women presenting with high blood pressure during the UK lockdown. This suggests that “women with hypertension aren’t being managed as they normally would, and undetected hypertension is a risk factor for stillbirth”, says Warland.
The studies are a call to arms to support maternal and newborn health services, especially in low-to middle-income countries, says Caroline Homer, a midwifery researcher at the Burnet Institute in Melbourne, Australia. “This is not the moment to reduce” these services, she says. Homer says that across the Asia-Pacific region, the maternal-health workforce has pivoted to working on the COVID-19 front line, and antenatal care services have reduced face-to-face contact with pregnant women. In some places, services have shut completely, she says.
But Pat O’Brien, the vice-president of the Royal College of Obstetricians and Gynaecologists in London, says the reasons behind this rise in the rate of stillbirths need further exploration.
“We are aware anecdotally of pregnant women presenting late with reduced fetal movements, which can be a sign their baby is unwell, and of women missing antenatal appointments. This may be due to confusion around whether these appointments count as essential travel, fear of attending a hospital or not wanting to burden the NHS,” says O’Brien.
To understand the full effects of the pandemic on pregnancies, future studies will need to use population-level data to assess outcomes in mothers who opted not to go to hospital and gave birth at home or in smaller facilities during the pandemic, says Emily Carter, a public-health researcher at Johns Hopkins University in Baltimore, Maryland. “Sometimes, we’re missing how dire the situation was, even before the pandemic, for certain segments of the population,” says Carter.
Nature 585, 490-491 (2020)
Ashish KC et al. Lancet Glob. Health https://doi.org/10.1016/S2214-109X(20)30345-4 (2020).
Khalil, A. et al. J. Am. Med. Assoc. 324, 705–706 (2020).
Kumari, V., Mehta, K. & Choudhary, R. Lancet Glob. Health 8, E1116–E1117 (2020).